MHW: Learning Collaborative Created to Inform Trauma Practices in Primary Care

Monday, November 6, 2017

Learning Collaborative Created to Inform Trauma Practices in Primary Care
Mental Health Weekly October 30, 2017

In the span of just a few months, a number of trauma-related incidents have occurred in this country — wildfires, hurricanes and mass shootings among them. Additionally, an estimated 60 percent of adults in the United States have experienced an adverse life event at least once in their lives, according to research pointed out by the National Council for Behavioral Health.                 

An urgency to educate health care providers on trauma-informed care is the impetus behind the National Council’s efforts to create and pilot a process for integrating trauma-informed approaches into primary care practices. The Kaiser Foundation is also a supporter.

The three-year initiative, Trauma-Informed Primary Care: Fostering Resilience and Recovery, commenced in July when the National Council convened a multidisciplinary group of 11 health care stakeholders to serve as the Practice Transformation Team for this initiative. The group convened again Oct. 27 in Oakland, California. Another meeting is scheduled for January.

The meeting focused specifically on finalizing the core domains of Trauma informed primary care, as well as identifying, outlining and assigning the change package content development activities, said Karen Johnson, director of trauma-informed services for the National Council.

“The change package will be tested and refined via a 16-month learning collaborative, which will include competitively selected nation- al primary care organizations,” she told MHW. The learning collaborative, which will pilot the change package, will launch in spring 2018, said Johnson.

Change package
The Practice Transformation Team will develop a change package—essentially a tool kit for health care providers that will include recommendations for standardized screening and assessment tools and evidence-based clinical interventions, according to the National Council.

“Our change package will definitely reflect evidence-based and best practices,” Johnson said, adding that practices involving mental health and substance use services are an area of focus as well.

“The Practice Transformation Team in-person meetings are focused on examining complex ideas and functional areas of interest which will impact the direction of the change package as a whole,” said Johnson. Upon finalization, the change package will be distributed nationally to the broader health care field, she said.

Helping a patient increase adherence to treatment is another out- come of this work, she noted. The initiative aims to also meet the three goals of Triple Aim: improve individual outcomes, improve population health outcomes and lower costs, noted Johnson.

Understanding the needs of primary care staff is very important in this effort. “You’ve got staff that’s highly stressed themselves,” she said. They may have to bale water out of their basement or the trauma- related incident may have impacted them in some other way, Johnson said. “If we don’t take care of staff, they’re not going to take care of the patient,” she said. “We understand that trauma in any form impacts individuals that are affected, even if we can’t see an outside wound or very visible damage.”

The front line
Virna Little, PsyD, LCSW-R, SAP, CCM, a member of the Practice Transformation Team, is a psychologist and social worker who has spent many years working in primary care, including community health centers. “We represent the front line of primary care providers and practices in the initiative,” Little told MHW.

“We would like to see increased engagement of front-line PC providers,” said Little, associate director for strategic initiatives at the Center for Innovation of Mental Health, affiliated with the City University of New York School of Public Health and New York Department of Health. “It’s important to educate primary care providers on the impact of trauma as it relates to a patient’s ability to care for his or her health,” she said. “This new program is helping to move the needle even farther.”

In primary care, there are a number of competing providers and lots of demands, she said. “They see patients for a short period of time,” she said. “A lot of the patients are chronically ill.” Primary care providers need to understand the importance of asking their patients about trauma, she said.

‘Inspiring’ effort
“I volunteered for this initiative because I thought it was such an inspiring topic area,” said Pamela S. Jacobs, adult mental health director for the Native American Rehabilitation Association in Portland, Oregon, and another member of the Practice Transformation Team. “The health system I work for addresses the needs of urban Native Americans,” she said. “There’s such a high degree of trauma in the Native American community, but there’s also a great capacity for healing. I’m looking forward to seeing what the final [change] package will be.”

“We’re trying to create a pro- gram where primary care clinicians can become trauma-informed,” said Jacobs. The team already has a set of ideas on ways to transform a practice to a trauma-informed practice; however, there is not yet a national agreed-upon way to do so, she noted.

Jacobs is a member of the sub- committee on evidence-based practices. Other subcommittees include assessment and organizational change, she said. One of the first things to do is define what evidence-based practices are for a primary care clinician to implement trauma-informed care in their practice, Jacobs noted.

Efforts to address trauma will include everyone on the ground: receptionists, nurses and PCPs. “The questions are how do you make medical treatment more trauma-informed, and how do we inform the larger behavioral health universe about why this is important?” noted Jacobs. “What are the expected outcomes?”

ACE research
Jacobs pointed to the Adverse Childhood Experiences (ACE) study conducted 1995 to 1997 by the Centers for Disease Control and Prevention and Kaiser Permanente, and considered one of the largest investigations of childhood abuse and neglect and later-life health and well-being.

More than 17,000 health maintenance organization members from Southern California receiving physical exams completed confidential surveys regarding their childhood experiences and current health status and behaviors.

The study found that the more childhood-related trauma incidents someone experienced, the more apt they were to suffer from chronic illnesses, such as diabetes, cardio- vascular disease and obesity, said Jacobs. “Now we want to take that knowledge and understanding to see if we can address those issues and make people more adherent to their medical treatment,” Jacobs added.

Jacobs added, “We want to approach people with sensitivity and awareness of their trauma history so that they can benefit [from the trauma-related approaches].” Some people who have experienced trauma become “self-blaming” regarding their suffering, said Jacobs. “We want to encourage people to get past that sensitivity to life,” she said. “We want people to feel more comfortable in their medical treatment environment.”

Any trauma-informed approach will include attention to mental health and behavioral health, she said. “I think integrated care goes hand in hand with trauma-informed care,” said Jacobs. PCPs will work very closely with mental health and behavioral health specialists, she noted. However, that is not the only piece of it — nursing staff, front desk receptionists and others will be involved, she added.

“It’s really everybody’s job to ad- dress this issue, from the moment someone makes an appointment,” Jacobs said. It’s also important to have mental health and behavioral health specialists involved so that anyone requiring longer-term care can be referred, she said.

For a number of individuals who have more complex needs, following a trauma event, it’s a long road to recovery, said the National Council’s Johnson. “Primary care physicians are well-positioned to address [the person’s] trauma,” she said. “Research tells us that many people are not seeking services from behavioral health providers. It’s very important that PCPs are equipped to identify trauma among their population.” •